Does Surgical Technique Influence Post-Tonsillectomy Haemorrhage? Our Experience

Abstract

Introduction and objectives

Tonsillectomy represents one of the main surgical procedures for the otolaryngologist, with haemorrhage being the most common postoperative. The objective of this study was to determine the post-tonsillectomy haemorrhage rate, and relate the surgical technique, diagnosis and patient age.

Methods

This was a retrospective study, from April 2012 to January 2014, covering 429 patients. We used the following surgical-dissection techniques: cold, Colorado needle and monopolar forceps. Haemostasis was carried out in every case with monopolar forceps and gauze compression.

Results

Post-tonsillectomy haemorrhage rate was 6.99%. According to the surgical technique used, with Colorado needle dissection, the bleeding rate we found was 7.07%; with monopolar forceps dissection, the rate was 20.4%; and with cold dissection, 2.9%. Of all haemorrhages, only 9 (2.09%) needed reintervention, of which 40% were performed with monopolar forceps dissection. The group with the largest bleeding rate was that of more than 14 years old. The diagnosis most associated with bleeding was peritonsillar abscess.

Conclusion

The lowest bleeding rate was found with cold dissection and monopolar forceps haemostasis (2.09%). Consequently, based on our experience and the results obtained in the study, we consider that surgical technique does influence post-tonsillectomy haemorrhage.

Resumen

Introducción y objetivos

La amigdalectomía representa uno de los principales procedimientos quirúrgicos del otorrinolaringólogo, siendo la hemorragia la complicación posquirúrgica más frecuente. El objetivo de este estudio es determinar la tasa de hemorragia postamigdalectomía y relacionarlo con la técnica quirúrgica, el diagnóstico y la edad del paciente.

Métodos

Se realiza un estudio retrospectivo con un período comprendido desde abril de 2012 a enero de 2014 con un total de 429 casos. Se emplearon las siguientes técnicas quirúrgicas de disección: fría, punta de colorado y pinza monopolar. La hemostasia se realizó en todos los casos con pinza monopolar y compresión con gasa.

Resultados

La tasa de hemorragia postamigdalectomía fue del 6,99%. Según la técnica empleada, con la disección con punta de colorado obtuvimos una tasa de sangrado del 7,07%, con disección con pinza monopolar del 20,4% y con disección fría del 2,9%. De todas las hemorragias, únicamente 9 (2,09%) necesitaron revisión quirúrgica, de las cuales el 40% habían sido realizadas con la técnica de pinza monopolar. El grupo con mayor tasa de sangrado fue el de más de 14 años; y el diagnóstico que más se relacionó con hemorragias fue el de absceso periamigdalino.

Conclusiones

La técnica con menor tasa de sangrado es la disección fría con hemostasia con pinza monopolar (2,9%). Por lo tanto, según nuestra experiencia y los datos obtenidos con este estudio, consideramos que la técnica quirúrgica sí influye en la aparición de hemorragias.

Introduction

Tonsillectomy is one of the oldest and most common procedures performed by ENT specialists. The indications for it, although they have changed through the years, cover both children and adults. These indications include chronic or recurring tonsillitis and to treat sleep apnoea/hypopnoea syndrome (SAHS).1, 2

Throughout history surgical techniques for tonsillectomy have varied. Changes have been made in line with the reduction in intra- and post-operative complications, lower short-term morbidity and shorter operating times, amongst others. However, to date, no technique appears to be clearly superior.³

Despite being generally considered low-risk surgery, tonsillectomy has the potential for extensive complications, of which postoperative haemorrhage is the most common.2, 4, 5, 6, 7

For this reason, the main objective of this study was to determine, according to our experience, the prevalence of this postoperative complication and to evaluate whether the technique used has an influence on its onset.

According to literature, the frequency of onset varies considerably depending on the author, ranging from 1.5% to 20%.1, 2, 5, 7, 8, 9, 10, 11 According to Sheshamani,³ the post-tonsillectomy bleed rate in a study which only included adults was 6%. Walker et al., in a prospective study which analysed 1133 tonsillectomies,⁸ observed that 4.5% of the patients presented with this complication. Monopolar forceps dissection presented a lower postoperative haemorrhage rate compared with cold dissection followed by coagulation, but presented a greater risk of surgical reintervention and blood transfusion.

Various surgical dissection techniques are used currently, from the traditional cold dissection, to different “hot” techniques, such as Colorado needle, coblator, electrocautery (monopolar and bipolar forceps), microdebrider, amongst others. Different techniques are also used to achieve haemostasis of the tonsil bed; these include gauze compression, coagulation with monopolar or bipolar forceps, suturing of pillars, coblator, etc.

In a study which compared the onset of haemorrhage after dissection by coblation and by electrocautery in 90 patients, only one episode of bleeding was encountered which occurred in a patient operated using electrocautery.¹²

In the study performed by Gallaher et al. which compared the onset of postoperative bleeding in 4776 patients, after dissection techniques using electrocautery, coblator and microdebrider, a haemorrhage rate of 1.7% was observed; the most frequent being after electrocautery (1.9%).¹

Comparing dissection by electrocautery and cold dissection, it can be concluded from the study performed by Lee et al.¹³ that, out of 337 patients, the postoperative bleed rate in adults operated using electrocautery was 12%, compared with those operated using cold dissection (5.5%). For children the haemorrhage rate in both groups was not statistically significant.

In the National Prospective Tonsillectomy Audit (NPT)¹¹ which compared 33,921 tonsillectomies performed using different surgical techniques, it can be seen that the lowest bleed rate was obtained with cold dissection with suturing of the pillars (.17%), followed by cold dissection and haemostasis with bipolar forceps (2.7%) and with monopolar forceps (2.9%). Bipolar forceps present a greater risk of bleeding at 4.6%, a similar percentage to that of the coblator. According to this study, the technique with the poorest results in terms of postoperative haemorrhage rate is dissection with monopolar forceps (6.6%).

In a meta-analysis which included 3384 patients,⁹ it was observed that the prevalence of post-tonsillectomy haemorrhage was around 3.3%. Evans and Khan performed a study which used telephone interviews with post-tonsillectomy patients and found that 40% of the patients had experienced some type of bleeding, however only 8% required admission to hospital and 3% required surgical reintervention.¹⁴

According to Blakley, the maximum acceptable post-tonsillectomy haemorrhage rate is 13.9%. However, rates have been reported in literature that vary in a range from 18% and 20%. This author considers that rates up to 5% are reasonable and those exceeding 14% should be monitored and their causes examined.¹⁰

Other secondary objectives in our study were to observe the relationship between post-tonsillectomy haemorrhage and the patient's age, the need for reintervention, the time elapsing between surgery and the onset of the complication and also the association with the preoperative diagnosis, and therefore, with the surgical indication.